ANGOLUAN, PB
ASSESSMENT EXPLANATION OF
THE PROBLEM
Subjective: The patient was diagnosed
with lack of sleep when
"it was difficult to nap vital signs was taken.
or take rest because of Because she wasn’t able to
the people passing by". sleep properly due to
people passing by and she
As verbalized by the
was easily disturbed by
patient.
neighbor’s patient.
Sleep is required to provide
Nursing Diagnosis:
energy for physical and
SLEEP mental activities. The
DISTURBANCES amount of sleep that
related to people passing individuals requires varies
by as evidenced by with age and personal
difficulty to nap or to characteristic.
take rest.
Sleep disturbance’s
characteristics are the ff;
change in normal sleep
pattern, reports of having
OBJECTIVES NURSING INTERVENTIONS
STO:
Within 30 minutes-1 hour
of effective nursing
interventions, the patient
will be able to:
a) identify and do
appropriate interventions to
promote sleep.
b) perform quiet activities
to improve sleep (e.g
listening to soothing music)
c) participate in
recommended treatment
program.
RATIONALE EVALUATI
Dx: STO:
 Identified presence of  To assess the specific cause (Goal Met)
physiological and psychological of lack of sleep this is
stressors mostly due to environmental Within 30 minu
and mental aspect. 1 hour of effec
nursing
 Sleep patterns are different to interventions, t
 Assessed past sleep patterns in
each individual. patient identifie
normal environment. (e.g and did approp
interfering agents, bed rituals, interventions to
etc. ) sleep, perform
 This can provide findings
activities and
why the patient is unable to
 Measured physiological participated in
sleep.
response to activity .e.g. changes recommended
in respiratory rate. treatment
accordingly.
 To determine whether the
 Monitored vital signs patient has lack of sleep.
LTO:
Tx:  Report of sleep disturbance (Goal Met)
woken up, dissatisfaction
with sleep and complaining
lack of rest. These are the
related factors are lack of
privacy/ sleep control,
noises, humidity and
interruptions ( e.g
therapies, monitoring,
laboratory tests)
SOURCE/S:
https://
www.nandadiagnoses.com/
disturbed-sleep-pattern/.
www.nurseslab.com
https://
nursingcareplan.blogspot.c
om/2009/01/ncp-nursing-
diagnosis-disturbed-
sleep.html
LTO:
Within 24-48 hours of
effective nursing
interventions, the patient
will:
a) report improved sleep
pattern
b) verbalize the feeling of
rested
C) achieves optimal amount
of sleep as evidenced by
normal vital signs
 Assisted with activities of daily is subjective and only the Within 24-48 h
living and promoted comfort patient can explain it. of effective nur
and rest. interventions, t
patient reported
 Promoted safety by constant  To help conserve energy and
improved sleep
monitoring, keeping bed in assist in coping with sleep
pattern and
comfort. disturbance.
verbalized the
 Because of inability to get feeling of reste
optimal amount of sleep, Also, achieved
 Ensured the patient took the safety may be compromised. optimal amoun
prescribed medication of sleep by provid
sleeping medicine with water. comfort and
 To increase quality of sleep interventions fo
and provide relaxation to the the said proble
client.
 Provide quiet environment and
comfort measures.
 This will help the patient to
sleep easily.
Edx:
 Educated on sleeping techniques
such as warm bath, avoid any
caffeine foods and physical
activities (e.g walking )  All these measures can help
the patient conserve energy
 Encouraged to increase the and increase sleep quality.
consumption of foods high in
vitamins and nutrients such as
banana, cherries, oats and
 vegetables ( e.g edamame, garlic
) these are the foods that may
help the patient to sleep.

 Advised to report promptly any  To ensure timely intervention

untoward feelings and concerns. and prevent complications.

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATI

THE PROBLEM

Subjective: The patient was STO: Dx: STO:

hospitalized due to
N/A uncontrollable vaginal Within 30 minutes-1 hour  Monitored vital signs (e.g  To monitor the baseline (Goal Met)
bleeding which leads to of effective nursing blood pressure, pulse and data and identify
interventions, the patient respiration rate) during and Within 30
Objective: blood transfusion. The will be able to: after activity. complications minutes-1 hou
patient had a history of effective nursi
* Uncontrollable anemia as evidenced by a) verbalize the  Discuss with patient and interventions,
bleeding. low blood circulation. understanding of risk family the cause and signs of patient verbali
factors of anemia and anemia and the consequences  To provide information
the understand
* history of anemia Anemia is one of the most therapy regimen that may occur. about causes, signs and
of risk factors
common health condition symptoms of the condition.
* Patient looks weak anemia and
throughout the world and b) have adequate
and has pale pinkish  Measured physiological therapy regime
the most affected people knowledge about proper
conjunctiva. response to activity .e.g. had an adequa
are women and children. nutrition that will help
changes in respiratory rate.  This can provide findings knowledge abo
In this condition the reduce anemia.
* tachycardia why the patient is unable to proper nutritio
patient’s red blood cell sleep. that will help
c) participate in
count is much lower than recommended treatment reduce anemia
is required for proper program. participated in
supply of oxygen to the treatment
whole body Tx: program.

 Assisted with activities of

daily living and promoted  Report of anemia is
comfort and rest. objective and observed by LTO:
Nursing Diagnosis: LTO:
SOURCE/S: the nurse
 Provide energy saving (Goal Met)
RISK OF ANEMIA Within 24-48 hours of
https://nanda- effective nursing techniques and monitor for
related to excessive  To enhanced rest to lower Within 24-48
nursingdiagnosislist.com/ interventions, the patient dizziness
blood loss as evidenced body’s oxygen hours of effect
by her history of anemia-nursing-diagnosis- will: nursing
care-plan requirements and tp prevent
anemia. increased risk of injury. interventions,
a) report improved red
patient reporte
/www.nurseslab.com blood cell count
 To enhance venous return. improved red
 Ensured the patient early
https://nursingcrib.com/ b) be free from weakness ambulation once tolerated blood cell cou
nursing-care-plan/nursing- and risk for complications  To provide information on and patient is f
care-plan-anemia/ has been prevented. how to properly manage the from weaknes
condition. and prevented
 Explore with family the ways
the risk for
of implementing measures for
complications
the proper management of
anemia.

Edx:
 To prevent blood loss and
 Educated on avoiding sharp conserve oxygen.
objects and avoid doing
strenous activities during
dyspnea.

 Encouraged to increase the  To increase hemoglobin and

consumption of foods rich in RBC levels in the blood.
iron and vitamins ( e.g beef,
chicken, spinach. Broccoli,
whole wheat bread )

 To ensure timely
 Advised to report promptly
intervention and prevent
any untoward feelings and
complications.
concerns.